Denali Premier Supplemental Agent Appointment 15%

7/31/2019 Denali Premier Supplemental Agent Appointment 15%

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Strength. Vision. Stability

RALA 08-2010

REQUISITION FOR AGENT APPOINTMENT

TYPE OF APPOINTMENT

Agent: Agency:

INDIVIDUAL INFORMATION

Last Name:

First Name:

Middle Name:

SS#: Birth Date: Birth Place:

Sex: Male Female Phone: Email:

Physical Resident Address: City:

County: State: ZIP:

BUSINESS INFORMATION

Agency/Firm Name: TAX I.D. #:

Phone: Fax: Email:

Physical Business Address: City:

County: State: ZIP:

I would like to be appointed by the following IHC Group carrier(s), please check all that apply:Standard Security Life Insurance Company of New YorkMadison National Life Insurance Company, Inc.

Independence American Insurance Company

I would like to be appointed by Companion Life Insurance Company:

List the state(s) in which you are licensed and want to be appointed in:

State: License #:

State: License #:

State: License #:

State: License #:

State: License #:

State: License #:

Name of Manager/Administrator/General Agent:

BACKGROUND - Use separate page if needed

1. Do you carry Errors and Omissions Protection? Yes No

2. Have you ever been:(a) convicted of any criminal felony, involving fraud, dishonesty or a breach of trust Yes No(b) convicted of an offense under the Violent Crime Control and Law Enforcement Act of 1994; Yes No(c) subject to a complaint filed against you by a state or a provincial Insurance Department? or Yes No(d) subject to disciplinary proceeding of any federal or state regulatory agency?If yes, provide explanation below:

Yes No

3. Are you bonded? Yes No


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RALA 08-2010

4. Has an application for bond ever been declined to you? Yes No

If yes, for what reason?

5. Have you ever been bankrupt or insolvent, personally or professionally? Yes NoIf yes, give details:

6. Have you ever been refused any license applied for? Yes NoIf yes, what state(s) and why?

7. Has your license ever been cited, suspended or revoked by any state(s)? Yes No

If yes, what state(s) and why?

8. Has your appointment ever been terminated involuntarily by an insurance company for reasons other than lack of production?Yes No

If yes, give details:

9. Is any charge by any state currently pending against you or against the agency or any member of the agency?Yes No

If yes, give details:

10. Do you work for or are you under contract to any financial institution such as a bank, a savings and loan association,any subsidiary, affiliate or holding company of such financial institution?If yes, please provide the name and address of the financial institution.

Yes No

11. Are there any outstanding judgments or liens (including state or federal tax liens) against you? Yes NoIf yes, give details:

12. Do you currently have any outstanding indebtedness to IHC, its carriers or affiliates or subsidiaries? Yes NoIf yes, give details:

CERTIFICATION/AUTHORIZATION

I certify, under penalty of perjury, that all answers and responses to questions or inquiries contained in this application are true, correct, andcomplete answers and responses. I further certify that I have read and am familiar with the sections of the insurance code in the state inwhich I am seeking appointment and that I am withholding no information that would affect my qualification for this appointment. I furthecertify that I am not prohibited by the Violent Crime Control and Law Enforcement Act of 1994 from engaging in the business of insurance

or that I have obtained consent from the appropriate insurance regulator to do so. I further certify that the number shown on this form is thecorrect Social Security Number/Tax Identification Number for 1099 tax reporting and that I am not subject to backup withholding by theInternal Revenue Service.

I also authorize the Insurance Company to order an investigative report as may be required in compliance with the Public law 91-505(Fair Credit Reporting Act). I understand that information for the report may be secured from financial sources, and/or public records, opersonal interviews with third parties, such as family members, business associates, and/or others with whom I am acquainted. Thisinquiry may include information as to my character, general reputation, personal characteristics, mode of living, or educationabackground. I understand that I have the right to make a written request within a reasonable period of time to receive a complete andaccurate disclosure of this information if I so desire.

All appointed agents must comply with all insurance laws, regulations and insurance department bulletins in the jurisdictions in which heis appointed. The applicant may not use, distribute, or publish any advertisement (as defined by the laws of the jurisdiction for which theapplicant is appointed), solicitation material, or proposal that references the Insurance Company which has not been filed with andapproved in writing by the Insurance Company. The applicant may not use, distribute, or publish any advertisement (as defined by the

laws of the jurisdiction for which the applicant is appointed), solicitation material, or proposal that references any insurance companythat IHC Health Solutions has a contract with, unless approved by that insurance company. The applicant agrees to assist andcooperate with the Insurance Company regarding any and all insurance department inquiries, complaints or investigations. Theapplicant agrees to assist and cooperate with any other insurance company regarding any inquiries related to that company.

Date: Signature: ____________________________________ Title:

Return completed form along with copies of your current license(s) to {Manager/Administrator/General Agent}:

[ ]


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PO BOX 35607 Phoenix AZ 85069-5607Phone 800-920-7125 Fax 602-906-4703

[email protected]

PRODUCER AGREEMENT

Producers Name: Date

1) Definitions. The following terms have the following meanings in this Producer Agreement:a) Payor means an insurance carrier issuing an insurance policy or certificate of coverage under which insurance

benefits are provided that has engaged IHC Health Solutions, Inc. to provide administrative or marketing servicesrelated to such policy or certificate of coverage.

b) Company means IHC Health Solutions, Inc. and any of its Affiliates.c) Affiliates means any other entity controlling, controlled by, or under common control with Company.d) Agreement means this Agreement and any schedule, appendix or supplement that may be included as part of

this Agreement now or in the future.e) Producer means the person authorized to solicit and procure applications for the insurance programs

administered by the Company who is named above and who executed this Agreement.f) Sub-producer means an individual employed by or under contract with a Producer to solicit, negotiate, sell or

place insurance business.

2) Solicitation. Subject to the authority granted to Company by each Payor, Company hereby authorizes Producer tosolicit and procure applications for the insurance programs identified in each schedule attached hereto, on a non-territorial, non-exclusive basis, subject to the terms and conditions of this Agreement.

3) Relationship of the Parties. Company and Producer each agree that:a) Producer is an independent contractor and this Agreement does not create a relationship of employer/employee

principal/agent, or any other similar relationship between Company and the Producer.b) Producer acknowledges that he/she is not, and shall not be, considered an agent or representative of Company and

that he/she will not expressly or impliedly represent himself/herself as such.c) Except where state law requires otherwise, Producer is an independent insurance agent representing Producers

clients.

4) Producers Responsibilities. Producer agrees to:a) Solicit applications for insurance policies and certificates of coverage issued by Payor or Company on behalf of

Payor; assist applicants to truthfully and accurately complete their respective applications for insurance coverageand submit such applications to Company promptly upon receipt of such applications from applicants.

b) Remit all gross premiums and/or policy fees received or collected by Producer promptly to Company with a fulland detailed statement.

c) Refrain from accepting any premium from any applicant or insured with the exception of the initial premium andapplicable fees collected with the application for coverage.

d) Strictly comply with all underwriting rules, regulations and instructions contained in the rate books, manuals orany other written material of any Payor with which Producer is appointed, and to observe and comply with theinsurance laws and regulations of the state or states in which Producer operates. In the event there is a dispute

between the parties hereto as to the interpretation of Payors regulations or instructions, Company in its solediscretion shall resolve any such dispute.e) Provide prompt, courteous service to certificate / policy holders.f) Pay (without reimbursement from Company) all Producer license fees and/or any other related fees or taxes

whether billed to Company or Producer.g) Provide Company with evidence of E & O coverage in such amounts and with such carriers as is reasonably

acceptable to Company.

Strength. Vision. Stability.


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h) Obtain prior written approval from Company of all marketing materials, application forms, and advertising usedby Producer in connection with this Agreement.

i) Remit an annual administrative processing fee to Company in the amount of $20.00. Company may deduct thisannual administrative processing fee automatically from Producers commissions.

j) Maintain current mailing address and contact information for Companys benefit.k) Keep records in such form as is reasonably required by Company and/or required under applicable laws and

regulations.

5) Restrictions on Producers Authority. Producer agrees that Producer has no authority and will not:a) Bind Company or any Payor by any promise or agreement, or incur any debt, expense, or liability whatever in its

name or account, or waive any of the provisions of policies administered by Company.b) Waive, alter, or modify any question on any application; permit any applicant to inaccurately answer any question

on any application; instruct any applicant not to disclose any particular medical condition on the application; ornotify an applicant that Producer has the authority to alter the terms of an insurance policy or certificate ofcoverage.

c) Pay or allow or offer to pay or allow, as an inducement to any proposed insured, any rebate of premium orconsideration or any inducement not specified in the policy or allowed by law.

6) Representations and Warranties. Producer represents and warrants as follows:a) Producer is currently licensed to solicit and procure applications for insurance policies and certificates of

coverage in the jurisdiction in which Producer will perform such functions and will maintain such license duringthe term of this Agreement.

b) Producer will comply with all statutes, regulations and administrative bulletins related to Producers performanceof Producers responsibilities hereunder.

7) Materials and Recordsa) All Company materials provided to Producer, including, without limitation, programs, manuals, tapes, guidelines

and any other information pertaining to Companys marketing methods, leads, or the products of Payors withwhich the Producer is appointed, or their content, if developed by Company, shall remain the sole and exclusiveproperty of Company.

b) Producers accounts, ledger, correspondence and other records pertaining to this Agreement shall be retained byProducer as required by applicable law, and open for inspection by authorized representatives of Company.

c) The parties agree that information and materials described in this section and otherwise provided by Companyderive independent economic value from not being generally known to other persons, and thereby constitute tradesecrets. As such, Producer agrees to maintain the confidentiality of such information and materials, except wheresuch materials are designed for release to other persons.

8) Compensation. Company and Producer each agree that:a) Company will pay compensation to Producer on behalf of Payors in accordance with the Compensation

Schedule(s) attached hereto.b) Company may, upon 30 days prior written notice, change or terminate said Compensation Schedule(s), or add

additional new policy forms or requirements and establish the rates of compensation thereon, or withdraw forms.

c) Commission, as defined in the Compensation Schedule(s), is vested and payable after termination of thisAgreement until the earlier of a) three years from the date of termination of this Agreement, or b) the date onwhich the monthly compensation amount due is less than $50.

d) The schedule of any renewal compensation set forth on the Compensation Schedule(s) begins with the secondpolicy year and is applicable thereafter as long as this Agreement is in full force and effect and Producer isrecognized as the agent of record by the policy holder.

e) Producer must be appropriately licensed in the state in which coverage is issued and must remain appropriatelylicensed in order to receive compensation related to the solicitation, procurement or sale of insurance policies andcertificates of coverage.


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f) Company will not issue payment to Producer for compensation less than $25. The compensation balance will beretained by Company until amount payable exceeds the $25 minimum.

g) If Company for any reason refunds any premium or part of a premium on any policy, any compensation paidProducer on the amount refunded shall be repaid to Company by Producer.

h) Company may offset against any compensation due Producer hereunder (including, without limitation, anycommissions and/or other compensation) any amounts due Company or Affiliates which may become due at any

time from Producer, and such amounts shall be a first lien against the compensation due Producer under thisAgreement.

i) Producer may not assign the compensation accruing under this Agreement or any interest therein except with theprior written consent of Company, and any assignment by Producer shall always be subject to the lien providedfor in the preceding paragraph, whether for debts or liabilities existing at the time of assignment or thereafterarising.

j) In the event that this Agreement is terminated pursuant to Section 10 or any condition set forth in Section 10(b)(iv) or (v) (vi)therein occurs after termination, all of Producers rights under this Agreement, includingProducers rights to any compensation to which Producer might otherwise become entitled shall terminateeffective as of the termination of this Agreement.

k) Compensation received during a calendar year will be reflected on that years annual 1099 tax form provided toProducer by Company.

9) Indebtedness. Company and Producer each agree that:a) Pursuant to the execution of this Agreement and for value received, Producer hereby promises and agrees to re

pay Company in full any indebtedness resulting from any and all special advances, charge-backs, dues, interest orany other charges owed by Producer to Company. Company has the right to charge and collect interest on debitbalances attributable to and owed by Producer. Company, its successors and/or assigns, is hereby granted acomplete, unconditional, and automatic first lien on any monies due or to become due under this Agreement andCompany may deduct such amounts from any monies due Producer as provided in Section 8 (g) hereof.

b) It is agreed that the unpaid balance owed shall accrue interest at the interest rate set forth in the attachedCompensation Schedule.. Company reserves the right to adjust the interest rate upon 30 days advance notice.

c) Producer hereby unconditionally guarantees to Company the full and timely payment of any and all moneys owedto Company by any Sub-producers of Producer whether directly or indirectly contracted with Company and/or

appointed where Producer is receiving a commission override.d) Upon termination of this Agreement for any reason, Producer agrees to immediately pay any debit balance owed

to Company, in full, upon demand by Company. After the debit balance has been fully satisfied, the remainder ofany Producer commissions or service fees will be paid to Producer as earned.

e) The Company reserves the right, without limitation or notice, to modify or terminate the amount of any advancecommission paid to Producer.

f) This entire Section 9 shall survive the termination of this Agreement. It is further agreed that in the event ibecomes necessary to enforce payment of this indebtedness through legal action, Producer agrees to bear thereasonable legal expenses, attorney fees and court costs incurred by Company.

10)Termination. Company and Producer each agree that:a) This Agreement, together with any addenda hereto, shall continue until terminated by either party pursuant to this

section.b) This Agreement, together with any addenda hereto, shall terminate:

i) Thirty days following written notice by either party mailed to the last known address of such other party.ii) Automatically without any notice upon Producers death, or total permanent disability.iii) Automatically at time of appointment renewal if the Producer has not placed any new business with Company

in the last 12 months.iv) Immediately upon notice from Company to Producer for any act of dishonesty, fraud or breach of any of the

terms of this Agreement as determined at the Companys sole discretion.


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v) Automatically without any notice upon revocation, termination or non-renewal of Producers license.vi) If attempt is made by Company to contact Producer in writing or via e-mail at last known mailing or e-mail

address and Producer fails to reply within 60 days of such attempt, in which event Company shall have theright to retain all future commissions of such Producer and such Producer shall forfeit any and all right tosuch commissions.

11)Assignment. No assignment of this Agreement or of any compensation due or to become due shall be valid unlessapproved in advance in writing by Company. Any assignment shall be subject to any existing or future indebtednessto Company by Producer.

12)Agent Appointment. Producer is responsible for costs associated with his/her appointment as determined by eachPayor. Company will not pay or advance on behalf of Producer such fees to any Payor. Producer agrees to pay for alsuch required appointment and / or state fees prior to appointment.

13)Liability. Producer shall indemnify Company for, and hold Company harmless against, any and all claims, actions,liabilities, losses, damages of any nature, whether compensatory or punitive, judgments, awards, or settlements,charges and expenses, including court costs and attorneys fees, that Company may at any time sustain or incur byreason of any unlawful or negligent act or omission of Producer, and any misrepresentation by Producer, or any

breach by Producer of the terms of this Agreement.

14)Confidentiality. Producer agrees to protect the confidentiality of protected health information in accordance withExhibit A which is attached hereto and incorporated herein.

15)Company Rights Company specifically reserves the right to:a) Cease doing business in any state upon 30 days prior written notice to Producer.b) Approve all transfers of reporting hierarchies prior to the effective date of the requested change.c) Discontinue or withdraw any plan of insurance.d) Amend this Agreement with 30 days notice at Companys sole discretion.

16) Indemnification. Producer shall indemnify and hold Company, Payor, and any of their employees, officers

directors, agents or representatives (collectively, the Indemnified Parties) harmless from and against any and allliabilities, damages, claims, costs and expenses, including, without limitation, reasonable fees and disbursements ofcounsel, arising in connection with, or incident to any breach or violation of any covenant or agreement contained inthis Agreement or otherwise arising out of any of the transactions contemplated by this Agreement. Producer shalnotify Company in writing within five (5) days of Producer becoming aware of any legal or administrative proceedingthat involves or could potentially involve an Indemnified Party in any manner whatsoever. Company may, in its soleand absolute discretion, determine whether to defend or settle any such claim. Company will be entitled to offset anylosses that are the subject of pending or unresolved indemnification claims against any and all payments due toProducer pursuant to this Agreement.

17) Applicable Law and Venue. This Agreement shall be governed by the laws of the State of New York, without regardto conflicts of law principles, and any interpretation of the language, intent, performance or obligation of this Contrac

shall be determined in accordance with the laws of the State of New York. This Contract is performable in New YorkCounty, New York, and any suit, action or proceeding by either party to this Agreement must be initiated and broughin New York County, New York. All sums or amounts due or to become due to either party hereto are payable in NewYork, New York.

18) Arbitration. Except as otherwise set forth herein, all disputes, controversies, or differences, whether arising orcommencing during or subsequent to the term hereof, which may arise among the parties out of or in relation to or inconnection with this Agreement which cannot be settled among the parties pursuant to the terms of this Agreement(including postponing settlement of such issue) shall be settled by arbitration in New York, New York, before an


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arbitrator of the American Arbitration Association in accordance with the commercial arbitration rules of theAmerican Arbitration Association.. Such arbitration shall be final and binding and shall be limited to an interpretationand application of the provisions of this Agreement. Any arbitration award shall be enforceable in any courtwherever located, having jurisdiction over the party against whom the award was rendered. With respect to any sucharbitration or enforcement proceedings, each party thereto shall bear its respective attorneys fees and all other costsand expenses associated with such arbitration, except as otherwise provided by law or rule and as directed by the

arbitrator.

19) Entire Agreement. Producer understands and agrees that:a) This Agreement is the entire agreement between the parties hereto and supersedes any and all previous contract

and agreements between Producer and Company.b) This Agreement is effective as of the date executed by Company below.c) Any schedule, appendix or supplement issued at a later date shall become effective at such later date as specified.d) Failure of Company to insist upon strict compliance with any of the conditions of this Agreement shall not be

construed as a waiver of such conditions, but they shall continue to be in full force and effect.e) No oral promises or representations shall be binding, nor shall this Agreement be modified except by agreement

in writing, executed by Company, except as otherwise set forth herein.f) This Agreement may be executed in one or more counterparts, each of which, when taken together, shal

constitute one original Agreement.

IHC HEALTH SOLUTIONS, INC., an Indiana corporation

Producer Signature By:

Printed Name: Printed Name: Jeffrey C. Smedsrud Authorized

Signatory

Date: Date:


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EXHIBIT A - CONFIDENTIALITY OF PROTECTED PERSONAL INFORMATION

1. Purpose. The Purpose of this Exhibit is to demonstrate both parties commitment to full compliance withall applicable privacy rules and regulations governing the use and disclosure of individually identifiable personalhealth and financial information by establishing contractual standards for such use and disclosure.

2. Definitions. Terms used this Exhibit and not otherwise defined in the Agreement are defined as follows:

(a) Disclose or Disclosure means the release, transfer, provision of access to, or divulging in any other mannerof information outside the entity holding the information.

(b) HITECH Act means the Health Information Technology for Economic and Clinical Health Act, found inTitle XIII of the American Recovery and Reinvestment Act of 2009, Public Law 111-005.

(c) Individual means the person who is the subject of protected health information and shall include personswho qualify as a personal representative.

(d) Individually Identifiable Health Information is health information, including demographic informationcollected from an individual, that:

(i) Is created or received by a health care provider, health plan, employer, or health careclearinghouse;

(ii) Relates to the past, present, or future physical or mental health or condition of an individual; theprovision of health care to an individual; or the past, present, or future payment for the provisionof health care to an individual; and

(iii) Either identifies the individual or with respect to which there is a reasonable basis to believe theinformation can be used to identify the individual.

(e) Personally Identifiable Financial Information means any information regarding a specific consumer that isobtained in connection with the services being provided hereunder.

(f) Privacy Rule means the Standards for Privacy of Individually Identifiable Health Information at 45 CFRPart 160 and Part 164, Subparts A and E

(g) Protected Personal Information (PPI) means Personally Identifiable Financial Information andIndividually Identifiable Health Information that is maintained in any form, including electronic mediaand/or transmitted in any form, including by electronic media.

(h) Required by Law has the same meaning as the term required by law in 45 CFR 164.501

(i) Use means, with respect to Individually Identifiable Health Information, the sharing, employmentapplication, utilization, examination, or analysis of such information within an entity that maintains suchinformation.

3. PRODUCERs Obligations. At all times PRODUCER agrees to:

(a) Refrain from using or disclosing PPI for any purpose other than as specifically permitted or required by theAgreement, including this Exhibit, as specifically required in order to perform the services for whichPRODUCER has been engaged or as permitted by law;

(b) Abide by an Individuals request to restrict the disclosure of PPI consistent with the requirements ofSection 13405(a) of the HITECH Act;

(c) Implement and utilize appropriate safeguards to prevent the Use or Disclosure of PPI other than as


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provided for by this Agreement;

(d) Mitigate, to the extent practicable, any harmful effect that is known to PRODUCER as a result of a Use orDisclosure of PPI by PRODUCER in violation of the requirements of this Agreement;

(e) Report to COMPANY any Use or Disclosure of PPI not provided for by this Agreement of whichPRODUCER becomes aware, including but not limited to any breach of unsecured PPI in compliance withany reporting requirements under regulations implementing the HITECH Act;

(f) Ensure that any contractor, consultant or vendor to whom PRODUCER provides PPI received fromCOMPANY, or created or received by PRODUCER on behalf of COMPANY, agrees to the samerestrictions and conditions that apply through this Agreement to PRODUCER with respect to suchinformation;

(g) Provide PPI to COMPANY or, as directed by COMPANY, to an INDIVIDUAL, in a reasonable time andmanner, in order to meet the requirements of the Privacy Rule, the HITECH Act, or applicable state law;

(h) Make any amendment(s) to PPI that COMPANY, or an INDIVIDUAL upon COMPANYs consent,directs PRODUCER to make in order to comply with the Privacy Rule;

(i) Make PRODUCERs internal practices, books, and records, including policies and procedures, relating tothe Use and Disclosure of PPI available to COMPANY or to the Secretary of the Department of Healthand Human Services for purposes of determining COMPANYs compliance with the Privacy Rules;

(j) Document Disclosures of PPI and information related to such Disclosures as would be required in order topermit COMPANY to respond to a request by an INDIVIDUAL for an accounting of such Disclosures ofPPI in accordance with the Privacy Rule and the HITECH Act;

(k) Make available to COMPANY within fifteen (15) days the information required to provide an accountingof disclosures in accordance with the Privacy Rule and the HITECH Act;

(l) Implement and utilize safeguards to Use or Disclose only the minimum necessary information in theperformance of PRODUCERs obligations under this Agreement; and

(m) Refrain from Using or Disclosing PPI for any marketing purposes not authorized by this Agreement;

(n) Make available to COMPANY within fifteen (15) days the information required to provide an accountingof disclosures in accordance with the Privacy Rule and the HITECH Act;

(o) Refrain from receiving any remuneration in exchange for any Individuals PPI unless (1) that exchange ispursuant to a valid authorization that includes a specification of whether the PPI can be further exchangedfor remuneration by the entity receiving the PPI of that Individual or (2) satisfies one of the exceptionsenumerated in the HITECH Act; and

(p) Refrain from marketing activities that would violate Section 13406 of the HITECH Act.

4. COMPANYs Obligations. At all times COMPANY agrees to:

(a) Notify PRODUCER of any limitation(s) in COMPANYs Notices of Privacy Practices, to the extent thatsuch limitation may affect COMPANYs Use or Disclosure of PPI;

(b) Notify PRODUCER of any changes in, or revocation of, permission by an INDIVIDUAL to Use orDisclose PPI, to the extent that such changes may affect PRODUCERs Use or Disclosure of PPI;

(c) Notify PRODUCER of any restriction to the Use or Disclosure of PPI to which PRODUCER has agreed,to the extent that such restriction may affect PRODUCERs Use or Disclosure of PPI;


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(d) Refrain from request that PRODUCER Use or Disclose PPI in any manner that is not legally permissible ifdone by COMPANY except to the extent necessary for any data aggregation services or PRODUCERsmanagement and administrative activities;

5. Permitted Usage of PPI. PRODUCER may Use or Disclose PPI for the following purposes or under the followingcircumstances:

(a) Except as otherwise limited in the Agreement, to provide the administrative services to COMPANY thatare described in the Agreement provided that such Use or Disclosure of PPI would not violate the PrivacyRule if done by COMPANY;

(b) Except as otherwise limited in the Agreement, for the proper management and administration ofPRODUCER or to carry out the legal responsibilities of PRODUCER;

(c) Except as otherwise limited in the Agreement, for the proper management and administration ofPRODUCER, provided that Disclosures are Required by Law, or PRODUCER obtains reasonableassurances from the person or entity to whom the PPI is Disclosed that it will remain confidential andUsed or further Disclosed only as Required by Law or for the purpose for which it was Disclosed to theperson or entity, and the person or entity notifies PRODUCER of any instances of which it is aware in

which the confidentiality of the PPI has been breached;(d) Except as otherwise limited in the Agreement, to provide data aggregation services to COMPANY as

permitted by the Privacy Rules;

(e) To report violations of law to appropriate federal and state authorities; and

(f) To contractors, consultants and vendors of PRODUCER in order to permit such contractors, consultantsand vendors to perform the services for which they have been engaged, subject to the conditions of thisAgreement.

6. Term and Termination.

(a) The Term of this Agreement shall be effective as of effective date of the Agreement and shall terminate as

of the termination of the Agreement.(b) Upon COMPANYs knowledge of a material breach of this Exhibit by PRODUCER, COMPANY shall

either:

(i) Provide an opportunity for PRODUCER to cure the breach or end the violation or terminate theAgreement in accordance with the Agreement; or

(ii) If cure is not possible, immediately terminate the Agreement.

(c) If neither termination nor cure is feasible, COMPANY may report the violation to the Secretary of theDepartment of Health and Human Services at its discretion.

7. Obligations upon Termination of this Agreement

(a) Upon the termination of the Agreement, PRODUCER shall return to COMPANY all PPI thatPRODUCER has in its possession and retain no copies of such PPI, except for that PPI necessary forPRODUCERs management and administrative activities. This provision shall apply to PPI that is in thepossession of contractors, consultants and vendors of PRODUCER.

(b) If PRODUCER is unable to return the PPI provided to PRODUCER by COMPANY or an INDIVIDUALor created by PRODUCER on COMPANY or an INDIVIDUALs behalf, PRODUCER shall:

(i) Provide to COMPANY notification of the conditions that make return or destruction infeasible


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and

(ii) Permanently destroy by shredding or otherwise destroying all paper or other hard copy media onwhich it is recorded, and/or erasing it from any hard drive, tape, diskette, compact disk or otherelectronic medium on which it has been stored using a method which renders the informationunrecoverable.

(c) If the return or destruction of the PPI is not feasible, PRODUCER shall extend the protections of thisAgreement to, and comply with its obligations herein regarding, the PPI and not make any further Use orDisclosure of the PPI.

8. Privacy Notices. COMPANY and PRODUCER agree to cooperate on the development and drafting of anyPrivacy Notices required to be provided by PRODUCER to INDIVIDUALS in order to ensure that such PrivacyNotices accurately reflect the current usage and disclosure of PPI and comply with any state or federal law orregulation that requires the provision of such Privacy Notices.

9. Amendment. The Parties agree to take such action as is necessary to amend this Exhibit from time to time as inecessary for COMPANY to comply with the requirements of the Privacy Rule and the Health InsurancePortability and Accountability Act of 1996, Pub. L. No. 104-191.

10. Regulatory References. A reference in this Agreement to the Privacy Rule means the Section of the Privacy Rulethen in effect or as amended.

11. Interpretation. Any ambiguity in this Agreement shall be resolved to permit COMPANY to comply with thePrivacy Rule and the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.


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HIERARCHY FORM

YOU MUST ATTACH COMMISSION ADDENDUMS THAT CORRESPONDTO THE PRODUCTS SELECTED ABOVE OR YOUR REQUEST WILL BE DELAYED!!


Agent Name________________________________________ Producer Number______________

Direct Upline (if not MGA/GA)__________________________ Producer Number______________

MGA/GA __________________________________________ Producer Number______________

Companion Life Insurance CompanyDefined Solutions Health Plans

Group Health Plans

Individual Health Plans*

Madison National Life Insurance CompanyIndividual Health Plans*

Group Health Plans

Hospital Indemnity Plan (HIP) (Select)*

Limited Medical Plans (Basic)*

One Life Dental

Group Dental

Vision

* Advance Commissions available

Standard Security Life Insurance Company ofNew York

Critical Illness*

Individual Health Plans*Group Health Plans

RX Paycard

Secure Dental One

Short Term Medical

Communicating for America Association, Inc.CA Association Premier (Stand Alone)CA Association Plans (sold with a individual medicalpolicy)*

US Fire & Marine

Overseas Travel Medical

*Advance Commissions available

Commissions to be Paid as Follows:Your direct upl ine and MGA/GA must sign this section if advanced commissions are requested

EARNED ADVANCE (If available) Effective Date:

Agent Name Producer Number

Direct Uplines Signature Producer Number

MGA/GAs Signature Producer Number

If this section not completed, your request will be delayed.


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Commission Assignment

I direct my compensation to be made payable as follows:

Agent/Agency Name: SSN TIN#:

Address:

City: State: Zip Code:

Dated at (City/State): on 20

Producer Signature:

If this section not completed, your request will be delayed.

Please refer questions concerning this form to your MGA/GAor to Agent Contracting: 800-920-7125

In the event of any conflict between the applicable Producer Agreement and this Hierarchy Form,the Producer Agreement shall control. Nothing contained herein shall be deemed to limit the rightsof Company under the Producer Agreement.


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COMPENSATION SCHEDULE TO PRODUCER AGREEMENT FOR

COMMUNICATING FOR AMERICA ASSOCIATION PREMIER PLANS

This Compensation Schedule to the Producer Agreement identifies (1) the product that the Producer is authorized

solicit and procure applications; and (2) the fee schedule applicable to such product. IHCHS and Producer e

agrees that this Compensation Schedule is subject to all of the terms and conditions of the Producer Agreement a

shall be made part of and attached thereto.

Compensation Schedule for Enroller Fee:

Compensation is based upon the retail collected dues, except to the extent any of the forgoing is required by state la

The maximum commission percentage payable hereunder, will be adjusted as required by applicable state law.

Percentages shown in this Compensation Schedule shall be reduced by any compensation/enrollers fee(s) paid to

writing agent. Compensation for the Enrollers fee is only paid to the writing agent and the top general agent on

case.

In the event that Producer receives advances payable hereunder, any outstanding advance loan balance will acc

interest at a rate equal to one (1%) percent per calendar month; interest rate is subject to change at Companys s

discretion upon 30 days written notice to Producer.

Producer shall not be entitled to any compensation for services of any kind rendered to or for Company by Produc

agents or employees of Producer except as enumerated in this Compensation Schedule.

First and renewal years for the

Premier Plans 1, 2, 3 & 4

15%


Documents

Denali Premier Supplemental Agent Appointment 15%